Diagnostic Imaging Pathways - Abdominal Plain X-Ray (Indications)

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This pathway provides guidance on the indications for a plain abdominal x-ray in adult patients.

Date reviewed: January 2012

Date of next review: January 2015

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SYMBOL

RRL

EFFECTIVE DOSE RANGE

None

0

Minimal

< 1 millisieverts

Low

1-5mSv

Medium

5-10 mSv

High

>10 mSv

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Teaching Points

Teaching Points

Indications for plain Abdominal X-Ray are:

Suspected bowel obstruction.

Suspected perforation.

Suspected foreign body.

Mod-severe undifferentiated abdominal pain.

Renal tract calculi follow-up.

xray

Plain Abdominal X-Ray

Eisenberg et al(1982) established the futility of indiscriminate use of AXRs showing 53.7% fewer AXRs could be performed if strict guidelines were followed. 1 A prospective study by Thomas et al showed that about 77% films were normal, increasing to 84% if unrelated or unsuspected findings were considered. 2 Even 25 years later, AXRs continue to be overused. Kellow et al (2008), in their retrospective study of 874 patients presenting to the Emergency Department, showed that 81% had normal or non-specific abdominal radiograph results 3

In their review of 277 cases, Lee showed that plain abdominal radiographs were not helpful in 57% and were misleading in another 1% 4

A few recent studies have shown that guidelines , as laid by the Royal College of Radiologists , are not being followed and a majority of plain abdominal radiographs requested on acute medical emergencies is still inappropriate. 5-7

The appropriate conditions for requesting a AXR as suggested by Jelinek et al are: 8

Bowel obstruction or paralytic ileus.

Pneumoperitoneum.

Renal /ureteric/bladder calculus.

Ingested foreign body.

Penetrating injury.

In this prospective trial , the authors were able to demonstrate a 50% reduction in the PAR requests and a further 16% reduction in inappropriate imaging by following the above indications.8

Similar indications were suggested by Eisenberg et al in their prospective study.1 They recommended the following criteria :

Patients with moderate or severe abdominal tenderness

Patients without moderate or severe abdominal tenderness, with high clinical suspicion of bowel obstruction, renal-ureteric calculi, trauma, ischemia, or gallstones if ultrasound is unavailable)

They demonstrated that following the above guidelines could have avoided around 53% of AXRs, as mentioned above.

Smith et al conducted a systematic review of literature to suggest indications for AXRs. They suggested the following indications:9

Suspected oesophageal foreign body (chest x-ray to be performed first)

Suspected sharp/poisonous foreign body

Rothrock et al, in their prospective study, showed that the presence of any of the following features-prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distension, or peritoneal signs-was 93% sensitive and 40% specific in predicting diagnostic or suggestive radiographs in patients with major disease. The positive and negative predictive values were 11% and 99%, respectively.13

Levine14 and Chiu 15, both have supported the use of AXR in pneumoperitoneum.

There is mixed evidence for the use of AXR in trauma. Some studies suggest that AXRs are neither useful nor cost-effective in stab wounds to the abdomen 20-22 while others favour AXRs in a trauma setting.1,8

Greene, in his review article, makes the following recommendations for the appropriate use of plain radiographs in an emergency department: 22

Avoid radiography for conditions unlikely to be associated with radiographic signs.

Avoid radiography in women of reproductive age group, unless a strong indication exists, and only after pregnancy has been excluded.

Avoid radiography where it will not lead to a change in management.

If radiography is indicated, request only a supine abdomen or a supine abdomen and erect chest x-ray. A complimentary view is to be requested only after reviewing the initial film.

Please remember that this leaflet is intended as general information only. It is not definitive and The Department of Health, Western Australia can not accept any legal liability arising from its use. The information is kept as up to date and accurate as possible, but please be warned that it is always subject to change

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